Traumatic Brain Injury

Epidemiology
Between

1.2 - 2 million Americans

sustain a TBI each year.
In the U.S. alone, it is estimated that
TBI is responsible for 50,000 deaths
and 235,000 hospitalizations each
year. Over 80,000 Americans are
disabled annually due to TBI

Defined
Traumatic

brain injury (TBI) is defined

as impairment in brain function as a
result of mechanical force.

The

current classification system, based

on the Glasgow Coma Scale (GCS)
mild (GCS score of 14 or 15)
moderate (GCS score of 9 to 13)
severe (GCS score of 3 to 8)

ANATOMI

Pathophysiology
The

brain consumes 20% of the

body's total oxygen requirement and
15% of total cardiac output.

MAP

ICP = CPP
The CPP is the pressure gradient
required to perfuse the cerebral
tissue

Clinical sign and symtoms:

Vomiting,
moderate

to severe headache,
focal neurologic complaint,
physical signs of a basilar skull fracture,
coagulopathy, and
DOC to comatous
Physical Examination
Examine the pupils (size, symmetry, and
reactivity)
Deformities (skull fracture)
signs of basilar skull fracture

Increased Intracranial
Pressure

An elevation in ICP further reduces the CPP and

cerebral blood flow
An ICP of >20 mm Hg increases subsequent
morbidity and mortality
Symtoms & sign of increased ICP include :
headache,
nausea,
vomiting,
seizure,
lethargy,
hypertension, bradycardia, and agonal
respirations.

 Signs

of impending transtentorial
herniation include unilateral or
bilateral pupillary dilation,
hemiparesis, motor posturing, and/or
progressive neurologic deterioration

Diagnostic Imaging
Skull X-ray
Adults with a GCS score of <15 should
undergo CT imaging

Management
Moderate and Severe TBI:
ABC with cervical spine stabilization.
The primary goals is prevent further secondary brain
injury (SBI).
SBI is prevented or minimized by correcting or
preventing hypoxemia, hypotension, anemia,
hyperglycemia, and hyperthermia, and by
evacuating intracranial masses
IV antibiotics if needed
Can use mannitol for increase ICP (1gr/kg of 20%
mannitol)
neurosurgical intervention

Mild Traumatic Brain Injury

No pharmacologic treatments for
mild TBI.
The primary ED objectives are to
identify patients who have
intracranial lesions requiring
neurosurgical intervention,

Airway and Breathing

Patients

with severe TBI require

prompt airway control with RSI

Circulation
Aggressive

fluid resuscitation
guidelines recommend that the systolic
blood pressure be maintained at >90
mm Hg & most studies in the guidelines
report keeping a MAP >80.
vasopressors should be used to maintain
MAP at 80 mm Hg to preserve CPP.
Control external and internal bleeding
quickly and maintain the hematocrit at
>30%.

Spesific head injury

Cerebral Contusion and Intracerebral

Hemorrhage

commonly occur in the

subfrontal cortex, in the
frontal and temporal lobes,
and, occasionally, in the
occipital lobes
.

Subarachnoid Hemorrhage
injuryto

the small
subarachnoid
vessels
Patients with
isolated traumatic
SAH may present
with
headache,
photophobia, and
meningeal signs.

Epidural Hematoma
An

epidural hematoma results when blood

collects in the potential space between the
skull and the dura mater
Source of bleeding is arterial in 85% of cases
(middle meningeal artery)
Clinical feature :
involves a significant blunt head trauma with

LOC,
lucid periode
subsequent rapid neurologic demise,
Strikes to the temporal bone or

The diagnosis
physical examination
findings.
CT scans : appear
biconvex (football
shaped),
The high-pressure arterial
bleeding of an EDH can
lead to herniation within
hours after an injury.

Subdural Hematoma
Two

common sources of bleeding

Tearing of bridging veins

Cortical laceration.

This

results in hematoma formation

between the dura mater and the
arachnoid
Brains with extensive atrophy, as
in the elderly and in alcoholics, are
more susceptible to acute
subdural hematoma

on CT imaging as
crescent-shaped
hematomas

Diffuse Axonal Injury

(DAI)
DAI

is the disruption of axonal fibers in

the white matter and brainstem
The underlying injury can result in
devastating and often irreversible
neurologic deficits.
Clinical feature :
coma for prolonged periods and
Demonstrate persistent brainstem dysfunction

(posturing) and autonomicdysfunction

patients

tend to have poor outcomes

PENETRATING HEAD
INJURIES
Mortality

rates from gunshot

wounds to the head approach 90%.
Clinical Features :
ICP increases,
The BBB breaks down,
CBF is altered, and
cerebral edema develops.
Cerebral autoregulation is lost,
CPP may fall

summary

Thank you

Refference
Head

Trauma in Adults and Children,

In Tintinallis Emergency Medicine: A
Comprehensive Study Guide; Judith
E. Tintinalli (7th ed); 254; USA: The
McGraw-Hill Companies, Inc. 2011
Kat i e L. Tata ris. Head Injuries.
Clinical Emergency Medicine.
McGraw-Hill Education. 2014;85;362367

Signs

Subfalcine
ACA compression:

contralateral leg paresis

Somnolence
midbrain

Uncal
(transtentorial)
Anisocoria to blown

pupil
Midbrain and PCA
compression:
Somnolence,
Contralateral
hemiparesis, occipital

Signs

Central tentorial
Somnolence/coma
Bilaterally blown

pupils
Decorticate/decerebra
te posturing
Bilateral midbrain,
PCA compression

Upward (rare)
Midbrain compression
Blown pupils
Somnolence/coma

midbrain

Brain Herniation
4

major brain herniation syndromes:

1. uncal (transtentorial),
2. central
3. cerebellotonsillar, and
4. upward posterior fossa

ICP Monitor

Preferred method in Guidelines